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THE SOCIO-ECONOMIC IMPACT OF MOBILE HEALTH Mobile communications will revolutionise the way that healthcare is delivered. From text messages with information for pregnant women to remote monitoring of the elderly, mobile technology is becoming an important part of global health systems. by Telenor and Boston Consulting Group (BCG) April 2012

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INTRODUCTION Increasing access to new health technologies that leverage the power of mobile communications—both in emerging and developed markets—promises to deliver better health solutions around the globe. The World Health Organization’s (WHO) definition of health as “a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity” should inform approaches to healthcare. Health is a fundamental good, both for individuals and for society as a whole. For individuals, good health leads to a better quality of life and education, enhancing their ability to find a job and to secure a higher lifetime income. In addition, healthier workers are less frequently absent from the workplace, and lower levels of absenteeism lead to cost savings for companies. For society as a whole, a healthier citizenry reduces pressure on overburdened hospitals, clinics, and medical professionals. It also reduces inequalities based on gender, income, or geography, and means that a greater proportion of the population can be employed, which increases gross domestic product, generates higher incomes for citizens, and increases tax revenues. This lowers demand for the services provided through public safety nets, charities, and non-governmental organizations. In short, an effective, accessible healthcare system is a prerequisite for economic growth and has clear benefits across society.

New solutions urgently needed In the face of the mounting pressures on healthcare systems in all countries, new solutions are urgently needed. Governments will be unable to continue to deliver quality services to all of their citizens with existing resources and traditional methods. Not only will they find budgets stretched as demands for healthcare services increase, but, in addition, large numbers of new medical professionals and support staff will need to be added to the sector’s workforce, putting further cost pressures on the healthcare ecosystem. In mature economies, there is a growing awareness of the potential crisis that could hit welfare systems if nothing is done to change the status quo.

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In contrast, developing economies often struggle to provide adequate healthcare to all of their citizens, especially in rural areas. Another aspect of the challenge developing countries face is their need to meet the health-related targets of the Millennium Development Goals (MDGs) by 2015. In Pakistan, for example, this will mean reducing by some 53 percent both the number of deaths per 1,000 live births of children under the age of five and the number of maternal deaths per 100,000 live births. Combating diseases such as HIV/AIDS and malaria will also stretch the resources of countries such as Bangladesh. To meet its MDG targets, Bangladesh will need to bring down the prevalence of tuberculosis per 100,000 people by some 60 percent.

MAKING HEALTH-RELATED SERVICES MOBILE

Whether serving older patients or those suffering from communicable diseases, mobile technology will be critical to solving future global health challenges. And with global market penetration of cell phones approaching 100 percent, mHealth is an idea whose time has come. The mobile phone has many advantages when deployed as a healthcare tool. First, even the simplest models can become powerful pieces of equipment: text messages and phone calls can deliver real-time, critical information quickly and easily, which means those living in remote areas can reduce unnecessary travel to health centers to consult with doctors and nurses. However, as mobile devices become increasingly sophisticated, they can be used to do more than simply transmit information and advice. Smartphones and broadband- enabled devices can become medical devices, used for monitoring vital signs and body functions or as videoconferencing equipment, facilitating remote consultations.

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In addition, as people use their mobile and smartphones to access an increasingly wide range of services—from interactive maps to weather forecasts—wellness and diet programs and exercise regimes can be added to the growing number of apps available at the touch of a button. Meanwhile, healthcare communications requirements are increasing exponentially as more patients have their health data electronically recorded (facilitating the sharing of information between patients and healthcare providers), and as remote monitoring systems make it easier to manage conditions such as heart disease and diabetes. In the process, the healthcare system is undergoing a cultural shift—from the traditional paternalistic approach, in which doctors talked and patients listened, to a more patient-centered approach in which individuals equipped with knowledge and information can play a much more active role in prevention and care. The world of apps is set to transform healthcare in the coming years. It is estimated that some 30 percent of smartphone users are likely to use wellness apps by 2015, while the smartphone and tablet are becoming the most popular technological development for doctors since the invention of the stethoscope. With a smartphone in their hands, individuals can engage in activities that improve their health and prevent disease. Some of the apps promote fitness, with guidance on diet and nutrition as well as incentives to work out, relax, or take up certain sports. With apps that guide users to everything from nature trails to theatre and concert performances, smartphones also provide the means for inspiration and relaxation. Mobile technology is also transforming the way doctors do their work. In the U.S., more than 80 percent of physicians are now using use smartphones for personal and general use, and increasingly, doctors will use their smartphones—as well as other devices such as tablets—as digital assistants. Mobile devices will allow them to access medical reference material, training content, and professional journals.

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The apps available on these devices will also turn them into tools that assist with patient monitoring, imaging, and bedside care. And many companies, seeing the commercial potential of these trends, are developing professional apps exclusively for healthcare professionals.

IMPACT OF mHEALTH

#1 – Frees up health resources For governments trying to cut the costs associated with operating a healthcare system, mHealth will help hospitals and health centers reduce paperwork. By speeding up processes, reducing the possibility for human error, and avoiding duplication, remote access to centralized electronic health records can reduce administrative burdens by 20 to 30 percent. This, in turn, helps address another of the problems countries are facing—shortage of skilled, qualified physicians and health workers—since cutting back on administration means that professionals can spend more time with their patients. Moreover, the apps enable patients to take a more active role in their own healthcare—managing appointments, updating prescriptions, and accessing their health records. And when patients take on more responsibility for their own care, their health improves. Evidence shows that 86 percent of women taking this approach undergo breast cancer screening (compared to the average of 57 percent) and 99 percent of people undergo cholesterol testing (compared to the average of 55 percent). Meanwhile, proactive care leads to a 10 percent reduction in primary and urgent care visits, since mobile technology often helps people with sudden health incidents to treat themselves or access information about health concerns. In countries where resources are under increasing pressure, mHealth has the potential not only to cut costs but also to free up badly needed capacity. In Sweden, for example, remote consultation and support could save $65 million a year in hospital nights for patients with chronic obstructive pulmonary disease (COPD), as patients would be able to use remote

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monitoring and video-enabled smartphones to rehabilitate at home. Patients with conditions such as heart disease, diabetes, and asthma could also be treated in this way. Trials in Nordic countries show that mHealth could generate a 50 to 60 percent reduction in hospital nights and re- hospitalizations for patients with COPD. Taking data collected from pilots and projects in Scotland and Norway, it is estimated that mHealth could reduce overall elderly care expenditure by 25 percent.

Mobile key to solving health challenges

#2 – Cuts costs and saves life By performing a wide variety of functions, mobile technology has the potential to increase both the efficiency and reach of healthcare services—maximizing healthcare professionals’ time—while also reducing costs of maintaining the delivery of quality healthcare along the value chain. It promises new remote diagnostic, monitoring, and data collection techniques, enhancing the efficiency of existing systems. And, critically for the countries we studied, it also has the potential to help patients take more responsibility for their own health, easing the pressure on healthcare workers and allowing a greater number of interventions to be made using technology. These are delivered through a wide range of instruments, enabling even non-mobile phone users to benefit.

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When it comes to empowering citizens, mobile communications offer a means of delivering public education and health campaigns via texts or voice messages sent to mobile devices and smartphones. And because they can be used to remind patients with chronic illnesses to take their drugs or make appointments for check-ups, mobile phones become a powerful tool in medical compliance management. For countries with aging populations, sensors connected to home alert systems improve safety and prevent needless deaths through accidents or falls. Mobile technology can do everything from checking on patients’ vital signs—allowing those suffering from diseases such as COPD to rehabilitate at home—to sending individuals reminders to take their medications on time. In these ways, technology will improve the lives of the elderly and chronically ill and help them to remain independent for longer. And because they require fewer face- to-face consultations and can spend more time at home, rather than in hospitals, mHealth cuts the costs associated with long-term care. In nations with many citizens in remote rural areas (often developing countries), mobile technology allows doctors to reach more patients. Pilot projects in India show that, using remote diagnostics and telemedicine, doctors can reach twice as many rural patients as they could through face-to-face consultations. mHealth also helps these countries combat communicable diseases. Because they can be used to send reminders to patients with tuberculosis (TB) to take their pills, mobile phones improve TB treatment compliance by between 30 and 70 percent, saving lives, since with effective medication compliance some 90 percent of those infected with TB can be cured. Pill boxes with integrated mobile capabilities can deliver similar benefits to those without mobile phones. More lives can be saved by mHealth in countries in which infant and maternal mortality remain severe problems. By delivering advice via SMS to

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pregnant mothers and health information to nurses and community health workers, these deaths can be reduced 30 percent. For governments, mHealth has the potential to reduce the per capita cost of healthcare while maintaining or increasing care quality. And as governments around the world start to explore different measures of human progress, wellbeing is increasingly being treated as an indicator. In this respect, mHealth has a role to play in improving new “gross national happiness” indicators by producing a happier, healthier populace, and has the potential to transform health service delivery.

Many stakeholders stand to benefit from mHealth

#3 – Houses a wide range of useful applications mHealth promises new remote diagnostic, monitoring, and data collection techniques, enhancing the efficiency of existing systems. When it comes to empowering citizens, mobile communications offer a means of delivering public education and health campaigns via texts or voice messages sent to mobile devices and smart phones. And because they can be used to remind patients with chronic illnesses to take their drugs or make appointments for

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check-ups, mobile phones become a powerful tool in medical compliance management. Mobile technology also increases the possibility of remote diagnosis by allowing patients and community workers to communicate with hospitals or healthcare centers via text or phone, maximizing the time of specialists and reducing trips to the hospital for patients with long-term illnesses. With rising demand for a wide range of healthcare workers—from physicians and nurses to therapists, paramedics, and dieticians—supplementing the education of these professionals is another area in which mobile communications can play an important role.

Seven categories of mHealth applications

#4 – Transforms lives Tracing the experiences of individuals illustrates the power of mobile technology when it is applied to healthcare. Take the case of a 26-year-old pregnant mother living in India. Without the assistance of technology, the mother, whose home is in a remote rural village far from health centers and hospitals, has no doctors to consult about her pregnancy. She does not recognize or understand warning signals and therefore risks dying during labor.

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With the assistance of a mobile phone, she can receive timely birth-related information and advice and become aware of any signs of danger during her pregnancy. Thanks to this information, she has a successful delivery and both mother and child go on to lead healthy lives. On the other side of the world, a 69-year-old widower living in Stockholm has been diagnosed with dementia. Forced to rely on traditional face-to-face health services, he is unable to call for help when he finds himself in need. Unused to dealing with a complex medical regime, he frequently forgets to take his pills. He even gets lost when he goes out, unable to find his way home. He is a constant source of worry to his family, who question whether it is safe for him to continue living in his own home. But when equipped with a range of mobile technology devices, the patient is able to manage his condition and continue to live at home, should he so desire. Automatic alarms alert healthcare professionals of anything unusual in his behavior and his family can track his whereabouts whenever he ventures outside the home. With easy-to-understand medical reminders sent to his phone, he remembers to take his pills on time, while wireless check-ups and electronic communications with his doctor mean he has to visit his health center less frequently. With the help of technology, he can remain in his own home for many years, living independently.

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Potential impact significant for all countries

While more than 500 mHealth projects are now operating globally, much still needs to happen so that more people can benefit from the technology. Importantly, the capabilities of a range of stakeholders from all sectors need to be brought together to create the infrastructure, systems, and innovative applications that will enable mHealth to achieve scale. Work must be done to remove regulatory barriers, and countries and companies must commit to common technical standards.

Application providers need to come up with new services. Health service providers, whether public or private, need to embrace the new technological solutions. Regulators need to create the legislative landscape that accommodates these new solutions and to provide incentives that can persuade more health sector organizations to embrace the technology. Common standards need to be developed and adopted to facilitate interoperability across the healthcare system.

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PROMOTING mHEALTH While the health sector has traditionally been inward-looking, developing specialized equipment and operating its own systems, the adoption of mHealth will demand far greater collaboration with a range of public and private sectors players than in the past, as well as increasing use of commercially available technology.

Capabilities from different sectors will need to participate in analysis, education, and evaluation if mHealth is ever to gain widespread acceptance. Without rigorous cost- benefit studies, for example, hospitals and medical practices will be reluctant to incorporate mHealth as part of the services offered.

In addition, these cost-benefit analyses will need to be comparable across regions and countries. Healthcare companies can play a critical role in developing common metrics with which to assess the benefits of mHealth.

Further tools in achieving widespread acceptance of mHealth will be education programs that are designed to inform patients and healthcare providers on the benefits of mHealth. Government, the private sector, and civil society organizations have a responsibility to coordinate their efforts, as no one sector can reach all corners of the healthcare ecosystem and its users.

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Individual players may lack incentives to push for mHealth solutions

TELECOMS PLAY A CRITICAL ROLE While split incentives and divided business models could serve as a barrier to the integration of mobile technology in healthcare, there is one industry that could play a powerful role in bringing together the diverse stakeholders in the mHealth system—the telecommunication sector.

Telecoms have in place the infrastructure and technical interfaces needed for mobile communications to become a tool in healthcare. These companies manage the backbone of the mobile network, its points of access, and its terminals. They also have considerable experience in providing sufficient coverage and quality of service.

The telecom sector has also shown that it is capable of scaling up solutions. It has experience in the development and implementation of international

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standards and is able to move quickly to capitalize on rapid innovation in products and services.

As companies versed in customer service and understanding customer needs, telecoms are in a unique position to develop user-centric services. Since they have a recognized position in the marketplace, customers trust them to handle sensitive information. Meanwhile, they are also used to dealing with regulatory authorities and a range of partners, both domestic and international, from NGOs to handset manufacturers.

While building communications platforms and customer relationships, the telecom sector could also assume a position as the facilitator at the heart of the mHealth ecosystem.

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